nutrition epidemiology zuzana derflerová brázdová dept. of preventive medicine, school of...
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Nutrition Epidemiology
Zuzana Derflerová Brázdová
Dept. of Preventive Medicine,
School of Medicine, Masaryk University, Brno
Chronology of application of the science of nutrition
• 2300 B.C., China: salt and cerebrovascular disease
• 47 B.C., Scribonius Largus: importance of diet in general health
• 25 B.C., Celsus: classified foodstuffs and emphasized their role in maintaining health
• 1542 A.D., Andrew Borde: A Dyetary of Health: factors affecting the health of man
• 1628 A.D., William Harvey: publication on circulation of the blood based on convicing experiments
Chronology of application of the science of nutrition
• 15th century, Albeek from Unitchov: excessive intake of fats and energy as a cause of premature death
Diseases related to nutrition(developed countries)
CVD
55% deaths(5.3 million)
Cancers
25% deaths(2.4 million)
Cirrhosis
1.8% deaths
(178thousands)
Osteoporosis
9% population
NIDDM
2.4 % population
Caries
93% popul.
Obesity12% men
15-20% women
Food allergies
7% population
Cataract18% 65-75 yrs
46% 75-85 yrs
Diseases related to nutrition(developing countries)
PEM Kwashiorkor Dysentery
Vit. A deficiency
IDA IDD
Cholera Hepatom
(aflatoxins)
Hepatitis A
Nutrition status at the beginning of the 3rd millenium
• 520 million of severely malnourished• 15 - 20 million victims of hunger a year • 300 million suffer by deficiency of vitamin A • 3.5 billion suffer from IDA• 853 million suffer from IDD• 75% of total population live in developing
countries, but they consume only 15% available energy
• 1 billion drink contamined water
Nutrition status in the beginning of the 3rd millenium
• 11-15 million children die because of hunger• 250 thousand children get blind because of
deficiency of vitamin A• 50% anaemic children (SE 52% vs. NW
10%)• 15 million children < 5 yrs get sick from
contamined water• More than 40% of all death in developing
countries are among children < 5 yrs • 54% from them are related to undernutrition
CVD in the Czech republic
• 1982: SMR 840.2 men and 546.6 women• 1995: SMR 708.0 men and 454.9 women
• 1986: SMR IM 239.0 men and 233.0 women• 1995: SMR IM 175.4 men and 77.9 women
• 1986: SMR Cer.d. 258.5 men and 203.2 women• 1995: SMR Cer.d. 176.3 men and 134.8 women
Role of Nutrition Epidemiology
• Problem detection – epidemiologic studies• Development of methods of dietary assessment• Definition of nutrition needs at the population
level• Formulation of dietary recommendations• Implementation of dietary guidelines • Influence of research trends• Education of professionals
Development of dietary assessment methods
• Recall
• Record
(weighting, estimation)
• Double portions
• FFQ
• Dietary history
• Dietary habits
• Food balance sheets
• Inventory method
• Food supply Exact result of any dietary
assessment method?
People eat.
Model of influence dietary behaviour at the population level
• Knowledge
• Attitude
• Behaviour
• Behaviour
• Attitude
• Knowledge
Atributes of dietary guidelines
• Based on scientific background • Analysis of local dietary habits • Social and cultural acceptance • Limited number of recommendations (the
most relevant from the prospective of population health)
• Easy to understand and remember, attractive, motivating to compliance and real behaviour changes
Dietary guidelines in terms of nutrients and energy
Živiny Modul A Modul B Modul C
Energie kJ
7466 10758 14049
Bílkoviny g
90.6 126.8 163.2
Tuky g
44.6 63.2 81.9
Sacharidy g
262.1 384.4 506.6
Vápník mg
977 1287 1599
Železo mg
21.4 30.7 40.1
Draslík mg
2753 4302 5552
Vláknina g
25.2 36.6 47.9
Vitamín A ug
1617 2177 2735
Vitamín B1 mg
1.9 2.7 3.8
Vitamín B2 mg
1.5 1.9 2.5
Vitamín B6 mg
2.2 3.2 4.2
Vitamín B12 mg
6.5 9.5 12.6
Vitamín C mg
107 150 191
Vitamín E mg
14.6 21.3 28.2
% tuku z celkové energie 23 22 22
Dietary guidelines for the Czech republic
• Cereals, bread, rice, pasta: 3-6 servings• Vegetables: 3-5 servings (a 100 g)• Fruit: 2-4 servings (a 100 g)• Milk and milk products:
2-3 servings (equiv. 300 mg Ca)• Meat, poultry, fish, eggs, pulses:
1-3 servings• Others: 1+1 servings (equivalent of 10 g fat or sugar)
Serving size
• Cereals, pasta, bread, rice: 1 slice of bread (60 g) 1 cup of rice or pasta (125 g) 1 cup musli• Vegetable
1piece approx. 100 g• Fruit
1piece cca 100 g
Serving size
• Milk and milk products 1 glass of milk - 300 ml 1 cup of yogurt approx. 180 ml 1 serving of „average“ cheese - 55 g
• Each serving is equivalent of 300 mg calcium
Recommended physical activity
• Minimum 3 times a week
• Aerobic excercise• Minimum 20 minutes
• + regular walking 1 hr daily
Evidence about non pharmacological intervention
• Physical activity
3 times a week, 30-40 minutes
aerobic, i.e. lactates < 4 mmol/l
by intensity > 7 kcal/min HDL-chol increases,
> 9 kcal/min total serum cholesterol decreases
Relation of physical activity to total cholesterol, HDL-chol, atherogenic index is linear, and to the level of TG logaritmic
Assessed sample before intervention
Cholesterol (mmol/l)
9,5 - 10,0
9,0 - 9,5
8,5 - 9,0
8,0 - 8,5
7,5 - 8,0
7,0 - 7,5
6,5 - 7,0
6,0 - 6,5
5,5 - 6,0
5,0 - 5,5
4,5 - 5,0
4,0 - 4,5
3,5 - 4,0
Poč
et o
sob
350
300
250
200
150
100
50
0
• Sample 1426 person, 882 men, 544 women
• Age 39,3 + 10,7 years• T-chol >5,2 mmol/l in
38,8% sample
Changes of HDL-chol before and after intervention
• Before intervention 1,04 + 0,13 mmol/l
• After intervention 1,16 + 0,14 mmol/l
• P < 0,001
554554N =
Po 3 měsícíchPřed intervencí
HD
L-c
ho
lest
ero
- l9
5 %
IS
(m
mo
l/l)
1,2
1,1
1,0
Changes of t-chol before and after intervention
• Before intervention 6,1 + 0,75 mmol/l
• After intervention 5,36 + 1,24 mmol/l
• P < 0,001554554N =
Po 3 měsícíchPřed intervencí
Ce
lko
vý c
ho
lest
ero
l - 9
5%
IS
(m
mo
l/l)
6,4
6,2
6,0
5,8
5,6
5,4
5,2
Cholesterol decreasing nutrients
• MUFA• PUFA• Sitostanol• Campestanol• Guar gum• Pectin• Fytosterols• Stilbenols
Cholesterol decreasing nutrients
• Beta- caroten• Lycopen• Cycloartenol• Beta-sitosterol• Sitostanol• Saponins• Mevinolin• Niacin ?
Cholesterol decreasing foods
• Vegetables• Fruits• Soya• Peanuts• Corn• Cereals• Psyllium• China green tea
Cholesterol increasing foods
• Fats with high content SFA
• Non filtered caffee (cafestol)
• Animal sources with high content of cholesterol…. (offals, eggs, skin, butter, …)
CINDI Dietary Guidelines – CVD prevention
Twelve steps of healthy eating:
1. Eat a nutritious diet based on a variety of foods originating mainly from plants rather than mainly from animal origin
CINDI Dietary Guidelines – CVD prevention
2. Eat bread, grains, pasta, rice or potatoes several times per day
3. Eat a variety of vegetables and fruits, preferably fresh and local, several times per day (at least 400 g per day)
CINDI Dietary Guidelines – CVD prevention
4. Maintain body weight between the recommended limits (BMI between 20-25) by taking moderate levels of physical activity, preferably daily
5. Control fat intake (not more than 30% of daily energy) and replace most saturated fats with unsaturated vegetable oils or soft margarines
CINDI Dietary Guidelines – CVD prevention
6. Replace fatty meat and meat products with beans, legumes, lentils, fish, poultry or lean meat.
7. Use low fat milk and dairy products (kefir, sour milk, yoghurt and cheese) that are low in both fat and salt.
CINDI Dietary Guidelines – CVD prevention
8. Select foods which are low in sugar and eat refined sugar sparingly, limiting the frequency of sugary drinks and sweets.
9. Choose a low salt diet. Total salt intake should not be more than one teaspoon (5 gr) per day, including the salt in bread, processed, cured and preserved foods. (Universal salt iodization where iodine deficiency is endemic).
CINDI Dietary Guidelines – CVD prevention
10. If consumed, limit alcohol intake to no more than 2 drinks (each containing 10 gr of alcohol) per day.
11. Prepare food in a safe and hygienic way. Steam, bake, boil or microwave to help reduce the amount of added fats, oils, salt and sugars.
CINDI Dietary Guidelines – CVD prevention
12. Promote exclusive breast feeding for about 6 months and recommended the introduction of appropriate foods at correct intervals during the first years of life.